WOUND CARE FOR NURSES AND GENERAL

Which of the following best describes the purpose of wound debridement? A. To reduce pain B. To remove necrotic tissue C. To prevent hemorrhage D. To minimize scar formation B. To remove necrotic tissue A wound with exposed bone, tendon, or muscle and slough or eschar is classified as: A. Stage I pressure ulcer B. Stage II pressure ulcer C. Stage III pressure ulcer D. Stage IV pressure ulcer D. Stage IV pressure ulcer What is the primary goal in the management of a pressure injury? A. To promote autolysis B. To reduce mobility C. To prevent infection and promote healing D. To use systemic antibiotics C. To prevent infection and promote healing Which type of dressing would be most appropriate for a heavily exudating wound? A. Transparent film B. Hydrogel C. Alginate D. Non-adherent gauze C. Alginate What is the primary function of a hydrocolloid dressing? A. To absorb large amounts of exudate B. To maintain a moist wound environment C. To prevent scar tissue D. To cool and soothe burns B. To maintain a moist wound environment Which of the following is a sign of wound infection? A. Minimal drainage B. Pale wound edges C. Increased pain and purulent discharge D. Formation of granulation tissue C. Increased pain and purulent discharge In the inflammatory phase of wound healing, which process occurs? A. Scar tissue formation B. Vasodilation and phagocytosis C. Collagen remodeling D. Epithelial regeneration B. Vasodilation and phagocytosis Which of the following factors can delay wound healing? A. Good nutrition B. Diabetes mellitus C. Moist wound environment D. Clean wound edges B. Diabetes mellitus What is the best intervention to prevent pressure ulcers in immobile patients? A. Apply cold compresses B. Turn the patient every 2 hours C. Use topical antibiotics D. Cover all bony prominences with tape B. Turn the patient every 2 hours A wound that is intentionally left open to heal from the base up is said to heal by: A. Primary intention B. Secondary intention C. Tertiary intention D. Reverse intention B. Secondary intention Which action can the nurse delegate to nursing assistive personnel (NAP) to help prevent the development of pressure ulcers in an older adult patient? A. Reposition the patient at least every 2 hours. B. Assess the patient's bony prominences every shift. C. Educate the family about the importance of healthy skin. D. Assist the patient in the selection of high-protein foods. A. Reposition the patient at least every 2 hours. Which practice protects the nurse from infection when changing the dressing on an infected pressure ulcer? A. Begin antibiotic therapy before the dressing change. B. Use appropriate personal protective equipment. C. Adhere to sterile technique during the intervention. D. Complete the dressing change in an effective, efficient manner. B. Use appropriate personal protective equipment. How would the nurse safely apply an enzyme debridement ointment? A. Daub ointment on dead tissue at the wound edges. B. Put ointment on a tongue blade, and gently spread it on the center of the wound. C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin. D. Apply a gauze dressing to ensure contact with the ointment. C. Apply ointment to necrotic tissue in the wound while avoiding contact with surrounding skin. The wound bed of a patient's pressure ulcer is red. What does this finding indicate to the nurse? A. Necrotic tissue B. Presence of slough C. Granulation tissue D. Development of an infection C. Granulation tissue Which measurements would the nurse use to calculate the surface area of a patient's pressure ulcer? A. Height and weight B. Length and width C. Length and depth D. Width and depth B. Length and width Which action reduces the nurse's risk for infection when changing the dressing of an infected abdominal wound? A. Begin antibiotic therapy before the dressing change. B. Use appropriate personal protective equipment (PPE). C. Adhere to sterile technique during the intervention. D. Complete the dressing change in an effective, timely way. B. Use appropriate personal protective equipment (PPE).